Category: Vascular
Keywords: CT, Pulmonary (PubMed Search)
Posted: 7/21/2008 by Rob Rogers, MD
(Updated: 10/31/2024)
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How good was that CT Pulmonary Angiogram You Ordered?
CT is currently the gold standard imaging modality for pulmonary embolism. Since we order these quite a bit in the ED, we should know some of the important nuances regarding interpretation of the scan. All of us at some point have looked at a pulmonary CTA and thought that it looked a bit "fuzzy" or perhaps it didn't "look right" This happens more often in obese patients. There is good literature to show that a suboptimal CTA misses clinically significant PE. So, it is important for emergency physicians to know a little about the CT scan ordered for our patients.
How can you know if the CT scan YOU ordered to rule out PE is really "good enough" to rule out PE?
So, a 34 yo obese patient who gets a CT scan to rule out PE, who has 170 HU in the main pulmonary artery, has not had an optimal CT. Thus, you really haven't ruled out PE even if the read is "negative." Often this is due to poor bolus timing.
American College of Radiology, Appropriateness Criteria, 2006
AJR, 2007
Kline, 2006-8
Category: Orthopedics
Keywords: Fracture, Management, Billing (PubMed Search)
Posted: 7/20/2008 by Michael Bond, MD
(Updated: 10/31/2024)
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Fracture Management:
In order to maximize billing when caring for patients with fractures two things should be done:
Finally, you should obtain post-reduction x-rays on any fracture that you manipulate and document that the patient is neurovascularly intact prior to discharge.
Category: Cardiology
Keywords: reflux, esophagitis, misdiagnosis, myocardial infarction (PubMed Search)
Posted: 7/20/2008 by Amal Mattu, MD
(Updated: 10/31/2024)
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The most common misdiagnosis in cases of missed acute MI is reflux esophagitis. Various studies have demonstrated the following factors that lead to this misdiagnosis:
1. 20% of patients with acute MI describe their pain using the words "indigestion" or "burning."
2. Almost 50% of patients with acute MI report an increase in belching during their ischemic symptoms.
3. 15% of patients get some relief of their ischemic pain with antacids and 7% of patients get complete relief of their ischemic pain with antacids.
4. 8% of patients report that their ischemic pain began while eating.
Before you ever write "Reflux esophagitis" or "GERD" on the chart of a patient you are about to send home, think twice about the possibility of acute cardiac ischemia.
Category: Pediatrics
Keywords: pediatric fever, pediatric seizure (PubMed Search)
Posted: 7/18/2008 by Don Van Wie, DO
(Updated: 10/31/2024)
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PEDIATRIC FEVER + SEIZURE = FEVER
When a child has a fever and a seizure, do the age appropriate workup for a fever and you won't go wrong!!!
Category: Toxicology
Keywords: Salicylate, aspirin, metabolic acidosisM (PubMed Search)
Posted: 7/17/2008 by Fermin Barrueto
(Updated: 10/31/2024)
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First Line Therapy: Urine Alkalinization (pH >7.5) by administrating NaHCO3
Other Indications for Hemodialysis in Salicylate Poisoned Patient:
Category: Neurology
Keywords: sciatica, sciatic nerve, foot drop (PubMed Search)
Posted: 7/16/2008 by Aisha Liferidge, MD
(Updated: 10/31/2024)
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Category: Critical Care
Keywords: noninvasive ventilation (PubMed Search)
Posted: 7/15/2008 by Mike Winters, MBA, MD
(Updated: 10/31/2024)
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Noninvasive Ventilation Pearls
Garpestad E, Brennan J, Hill NS. Noninvasive ventilation for critical care. Chest 2007;132:711-20.
Category: Vascular
Keywords: Pulmonary Embolism, Pregnancy (PubMed Search)
Posted: 7/14/2008 by Rob Rogers, MD
(Updated: 10/31/2024)
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Evaluating for Pulmonary Embolism During Pregnancy
Highest risk of PE is within the first week postpartum
Acceptable, safe, and medico-legally sound strategies to rule out PE in pregnancy:
**For explanation of PERC rule, see earlier pearl.
Kline J, Carolinas Medical Center, 2006-2008 published data
Category: Cardiology
Keywords: myocarditis, pericarditis, myopericarditis (PubMed Search)
Posted: 7/13/2008 by Amal Mattu, MD
(Updated: 10/31/2024)
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The pericardium is electrically silent, and so true acute pericarditis should not be associated with ECG changes. STE actually implies concurrent involvement of the myocardium; i.e. myopericarditis. The greater the degree of myocardium involved, the more ECG changes will develop, including STE, AV blocks, and dysrhythmias. Additionally, myocardial involvement is implied by elevated troponin levels, the magnitude of which is related to the amount of myocardial involvement.
[Imazio M, Trinchero R. Myopericarditis: etiology, management, and prognosis. Int J Cardiol 2008;127:17-26.]
Category: Orthopedics
Keywords: scaphoid, fracture (PubMed Search)
Posted: 7/13/2008 by Michael Bond, MD
(Updated: 10/31/2024)
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SCAPHOID FRACTURE:
Category: Pediatrics
Keywords: Intussusception (PubMed Search)
Posted: 7/12/2008 by Don Van Wie, DO
(Updated: 10/31/2024)
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Category: Toxicology
Keywords: lactic acidosis, metformin, renal failure (PubMed Search)
Posted: 7/10/2008 by Fermin Barrueto
(Updated: 10/31/2024)
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Perrone et al. Occult metformin Toxicity in Three patients with profound lactic acidosis. J Emerg Med 2008, June 18.
Category: Neurology
Keywords: neurointerventionalist, vascular dissection, ischemic stroke, subarachnoid hemorrhage (PubMed Search)
Posted: 7/9/2008 by Aisha Liferidge, MD
(Updated: 10/31/2024)
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Top Reasons to call your Neurointerventionalist:
Category: Critical Care
Keywords: hypotension, trauma, elderly (PubMed Search)
Posted: 7/7/2008 by Mike Winters, MBA, MD
(Emailed: 7/8/2008)
(Updated: 10/31/2024)
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Hypotension begins at 110 mmHg?
Eastridge BJ, Salinas J, McManus JG, et al. Hypotension begins at 110 mmHg: redefining hypotension with data. J Trauma 2007;63:291-9.
Category: Critical Care Literature Update
Keywords: etomidate, adrenal insufficiency (PubMed Search)
Posted: 7/7/2008 by Mike Winters, MBA, MD
(Updated: 10/31/2024)
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Recent Articles from the Critical Care Literature
Duration of adrenal insufficiency following a single dose of etomidate in critically ill patients
Category: Vascular
Keywords: Pulmonary Embolism, Cancer (PubMed Search)
Posted: 7/7/2008 by Rob Rogers, MD
(Updated: 10/31/2024)
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Ruling Out PE in Cancer Patients: Use D-Dimer??
Most of us are aware of the data that suports using a highly-sensitive d-dimer combined with low-moderate risk score to r/o PE. Sounds simple enough. What about using d-dimer in a cancer patient to rule it out? Well, this is being studied more and more.
Most of us would be a little uneasy about using a d-dimer as a stand-alone test to r/o PE in a cancer patient. After all, they have cancer, aren't they high risk?
The following study showed that the there was a VERY high negative predictive value and a VERY high sensitivity of a negative d-dimer in this group of cancer patients.
Abstract |
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PURPOSE: To prospectively evaluate (a) the diagnostic performance of D-dimer assay for pulmonary embolism (PE) in an oncologic population by using computed tomographic (CT) pulmonary angiography as the reference standard, (b) the association between PE location and assay sensitivity, and (c) the association between assay results and clinical factors that raise suspicion of PE. MATERIALS AND METHODS: This HIPAA-compliant study had institutional review board approval; informed consent was obtained. Five hundred thirty-one consecutive patients were clinically suspected of having PE; 201 were enrolled (72 men, 129 women; median age, 61 years) and underwent CT pulmonary angiography and D-dimer assay. Relevant clinical history, symptoms, and signs were recorded. CT images were interpreted, and the location of emboli was recorded. The negative predictive value (NPV), positive predictive value (PPV), sensitivity, specificity, and diagnostic likelihood ratios of the D-dimer assay results were calculated. RESULTS: Forty-three patients (21%) had pulmonary emboli at CT. D-Dimer results were positive in 171 patents (85%). The NPV and sensitivity were 97% and 98%, respectively. The specificity and PPV were 18% and 25%, respectively. No association was shown between clinical history, symptoms, or signs and NPV, PPV, sensitivity, or specificity or between location of PE and sensitivity. CONCLUSION: D-Dimer results have high NPV and sensitivity for PE in oncologic patients and, if negative, can be used to exclude PE in this population. Combining the assay with clinical symptoms and signs did not substantially change NPV, PPV, sensitivity, or specificity. |
King V, Vaze AA, Moskowitz CS, et al. D-dimer assay to exclude pulmonary embolism in high-risk oncologic population: correlation with CT pulmonary angiography in an urgent care setting. Radiology. 2008 Jun;247(3):854-61
Category: Cardiology
Keywords: myocarditis, pericarditis, myopericarditis (PubMed Search)
Posted: 7/7/2008 by Amal Mattu, MD
(Updated: 10/31/2024)
Click here to contact Amal Mattu, MD
Both acute pericarditis and myopericarditis are intensely inflammatory. As a result, CRP testing is extremely sensitive for these conditions and is excellent for evaluating their presence or absence.
Imazio M, Trinchero R. Myopericarditis: etiology, management, and prognosis. Int J Cardiol 2008;127:17-26.
Category: Orthopedics
Keywords: Arthrocentesis, Joint, Fluid, Septic (PubMed Search)
Posted: 7/6/2008 by Michael Bond, MD
(Updated: 10/31/2024)
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Joint Fluid Analysis:
This is hte session in Baltimore for crab eating and beer drinking so we begin to see an increase in Gout pain. For those that are presenting with their first episode and you are concerned that they might have a septic joint, I am including this pearl to help analysis the fluid you will obtain from arthrocentesis.
Diagnosis | Appearance | WBC | PMNs | Glucose % of Blood Level | Crystals | |
Normal | Clear | <200 | <25 | 95 - 100 | None | |
Degenerative Joint Disease | Clear | <4000 | <25 | 95 - 100 | None | |
Traumatic Arthritis | Straw colored | <4000 | <25 | 95 - 100 | None | |
Acute Gout | Turbid | 2000 - 50,000 | >75 | 80 - 100 | Negative birefringence | |
PseudoGout | Turbid | 2000 - 50,000 | >75 | 80 - 100 | Positive birefringence | |
Septic Arthritis | Purulent / turbid | 5000 - > 50,000 | >75 | < 50 | None | |
Rheumatoid Arthritis | Turbid | 2000 - 50,000 | 50-75 | ~75 | None |
To view a gout crystal click this link.
To view a pseudogout crystal. Click this link
Pearls:
Benjamin GC. Arthrocentesis. In: Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine. 3rd ed. Philadelphia: Saunders; 1998:919-932.
Category: Critical Care Literature Update
Keywords: intracerebral hemorrhage, recombinant factor VIIa (PubMed Search)
Posted: 7/6/2008 by Mike Winters, MBA, MD
(Updated: 10/31/2024)
Click here to contact Mike Winters, MBA, MD
Recent Articles from the Critical Care Literature
Efficacy and Safety of Recombinant Activated Factor VII for Acute Intracerebral Hemorrhage.
Category: Pediatrics
Keywords: Kawasaki Disease; Cardiac; Coronary Aneurysm (PubMed Search)
Posted: 7/4/2008 by Don Van Wie, DO
(Updated: 10/31/2024)
Click here to contact Don Van Wie, DO
Cardiac Involvement in Kawasaki Disease
So the Pearl is if you have a pediatric patient with a complaint of Chest Pain, ask if there was any history of Kawasaki Disease and get an EKG ASAP if the answer is yes!
Shah B. Lucchesi M. Atlas of Pediatric Emergency Medicine. McGraw-Hill Companies. 2006.